A Minor Child Form

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					                                                       Consent to Treat Minor Child Form
                                                                                                  Date ____/____/_______
I hereby authorize :


___________________________________________ of Whole Life Massage to administer massage therapy, bodywork
or body treatments to my child or dependent as I deem necessary. I intend this consent form to cover the entire course
of treatment for this child’s present condition. I further intend this consent for any future condition(s) for which I seek
treatment for this child.


Full Name of Child ___________________________________________________________________________________


Signature of Parent or Guardian ________________________________________________________________________


Printed Name of Parent or Guardian __________________________________Relationship to child _________________

				
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posted:8/11/2009
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